A Nurse-Led Physician-Directed System for Providing Optimal Cardiac Care Despite efficacious secondary prevention interventions for coronary heart disease (CHD) and recognizing care delivery organization importance, CHD patients are not adequately identified and treated. The overall goal of this proposal is to test the hypothesis that the proportion of CHD patients meeting optimal cardiac care (OCC) criteria will increase in a multi-site primary care (PC) practice in association with implementation of a nurse-led physician-directed system that provides optimal cardiac care (NLPD-OCC). The specific aims are to evaluate 1) if exposure to NLPD-OCC increases the proportion of CHD patients meeting OCC criteria relative to optimal care of patients with a comparator condition, 2) the potential business case for system investment, 3) patient and physician/nurse satisfaction with NLPD-OCC, 4) clinic process adaptations with OCC. The study design is a non-equivalent control group design in which NLPD-OCC is implemented in 5 PC clinics and compared to optimal care outcomes for patients in a diabetes mellitus care program in the same medical practice. The intervention is a nurse-led physician-directed care management system for optimal care of CHD patients. Nurses identify the patients; ascertain if care is optimal; if not, initiate steps to achieve it, working with the patient's PC physician. Principles directing nursing activities include using evidence-based guidelines for patient care, coordination and communication among patients, providers and care sites; physician consultation; proactive patient monitoring between visits; anticipating patient and provider needs; encouraging patient's active involvement in their care; and problem solving. Subjects will be adults aged 40 or older, CHD patients of a PC physician in a Wisconsin medical practice. All CHD patients, less those meeting minimal exclusion criteria, receive the intervention. The primary outcomes of the study are OCC criteria of LDL level, BP level, tobacco use and aspirin use in CHD patients. Data will be obtained from patient chart review. We will examine the business case for the cardiac care management system by comparing investment costs of the system to changes in medical utilization and billing. Satisfaction levels of physicians, nurses and patients will be surveyed pre and post intervention. Adjustments to clinic roles and processes will be described qualitatively.